A.S.P.E.N. Clinical Guidelines: Nutrition Support of the Critically Ill Child

# Guideline Recommendations Grade

1

1A) Children admitted with critical illnesses should undergo nutrition screening to identify those with existing malnutrition and those who are nutritionally-at-risk.

D

 

1B) A formal nutrition assessment with the development of a nutrition care plan should be required, especially in those children with premorbid malnutrition.

E

2

2A) Energy expenditure should be assessed throughout the course of illness to determine the energy needs of critically ill children. Estimates of energy expenditure using available standard equations are often unreliable.

E

 

2B) In a subgroup of patients with suspected metabolic alterations or malnutrition, accurate measurement of energy expenditure using indirect calorimetry (IC) is desirable. If IC is not feasible or available, initial energy provision may be based on published formulas or nomograms. Attention to imbalance between energy intake and expenditure will help to prevent overfeeding and underfeeding in this population.

D

3

There are insufficient data to make evidence-based recommendations for macronutrient intake in critically ill children. After determination of energy needs for the critically ill child, the rational partitioning of the major substrates should be based upon understanding of protein metabolism and carbohydrate- and lipid-handling during critical illness.

E

4

4A) In critically ill children with a functioning gastrointestinal tract, enteral nutrition (EN) should be the preferred mode of nutrient provision, if tolerated.

C

 

4B) A variety of barriers to EN exist in the pediatric intensive care unit (PICU) Clinicians must identify and prevent avoidable interruptions to EN in critically ill children.

D

 

4C) There are insufficient data to recommend the appropriate site (gastric vs post-pyloric/transpyloric) for enteral feeding in critically ill children. Post-pyloric or transpyloric feeding may improve caloric intake when compared to gastric feeds. Post-pyloric feeding may be considered in children at high risk of aspiration or those who have failed a trial of gastric feeding.

C

5

Based on the available pediatric data, the routine use of immunonutrition or immune-enhancing diets/nutrients in critically ill children is not recommended.

D

6

A specialized nutrition support team in the PICU and aggressive feeding protocols may enhance the overall delivery of nutrition, with shorter time to goal nutrition, increased delivery of EN, and decreased use of parenteral nutrition. The affect of these strategies on patient outcomes has not been demonstrated.

E